The introduction of direct oral anticoagulants (DOACs), including the oral direct thrombin inhibitor dabigatran etexilate, ushered in a new era for chronic thrombotic disease management. Despite evidence of DOAC safety, there are valid concerns regarding an anticoagulant effect in the setting of uncontrolled bleeding. Unlike the coagulation defect induced by vitamin K antagonists, which is correctable with vitamin K and coagulation factor replacement, there were no agents to reverse DOAC anticoagulant effect until recently. Idarucizumab is a monoclonal antibody fragment that binds to dabigatran with high affinity, and andexanet alfa is a form of deactivated factor Xa that acts as a decoy to bind factor Xa inhibitor molecules.1,2 These reversal agents rapidly correct the coagulopathy induced by the respective DOACs and should improve clinical outcomes. In the multicenter, open-label, single-cohort REVERSE-AD study (Reversal Effects of Idarucizumab on Active Dabigatran), idarucizumab corrected laboratory indices of anticoagulation and reduced the level of active drug in dabigatran-treated individuals with uncontrolled bleeding or the need for urgent surgery.3 Gastrointestinal bleeding accounted for 46% (137/301) of bleeding events in REVERSE-AD, the characteristics and outcomes of which are reported by van der Wall et al4 in this issue of Circulation.
Circulation. 5 February, 2019;139:757-759.